Page 4 - Neurological examination of children

Motor function Cranial nerves I-XII

Observe: Normal or abnormal movements. Range of movements. Muscle tone, bulk, and 1. Can be examined using a hidden mint sweet
power. Deep tendon reflexes: Let the child touch the hammer— or demonstrate its use on
parent first. Plantar response, cerebellar function, rapid alternating movements. 2. Visual acuity develops with age: Infants should be able to see and follow
a moving face. Toddlers may see, note and follow a small object like a
paper clip. Children from 2 years and up may be tested with Kay charts
https://www.kaypictures.co.uk/, the Tumbling E-chart or the Osterberg
Power can be graded 0-5 Deep tendon reflexes can be graded 0-4 visual acuity picture (Figure 3). Testing at 3 or 6 meters is preferable.
0: No contraction 0: No reflexes Figure 3 is for practice at approximately one meter.
1: Palpable or visual contraction 1: Weak reflexes
2: Movement with gravity eliminated 2: Normal reflexes 3. Total oculomotor palsy: Dilated pupil, ptosis of upper lid, paralysis of
3: Movement against gravity 3: Slightly hyperreflexic medial, inferior and superior rectus muscles. Differential: Horner
4: Movement against resistance 4: Severely hyperreflexic. Increased syndrome is a disruption of sympathetic fibres to the eye causing: miosis,
5: Normal power zone. Sustained clonus may be mild ptosis and enophthalmus.
(Medical Research Council 1976. Aids to the elicited.
examination of the peripheral nervous (..) 4. Trochlear palsy: Affected eye is rotated upwards with compensatory
system HMSO, London) inclination of the head to the normal side.

5. Ask the patient to clench teeth and waggle jaw from side to side.
Fine motor function: Observe drawing skills. Use of right/left hand. Age appropriate? Sensation.
Finger opposition.
6. Abducent palsy: Affected eye is deviated medially, with a compensatory
Gross motor function: Observe how the child gets from supine to the standing position. head turn of the head to the paralyzed side
Children up to 3 years will turn prone to get up; beyond this age weakness or low muscle
tone must be suspected. 7. Power: Smile. Show teeth. Eye closure.

Instruct the child and demonstrate: Stand with eyes closed. Stretched arms test. Walk 10 8. Hearing: Whispering voice, weak
meters and include a half turn. Hop on one leg. Stand on one leg. Walk on heels and toes. rattling.
Walk on outer borders of the feet (Fog’s test). Run.
9+10 Listen for hoarseness or stridor.
Observe the soft palate, the gag
About this folder reflex and swallowing.

This folders mission is to support clinicians doing clinical tests in children with neurologi-
cal symptoms. The 1. version in Danish was published in 2002. The 1. international version
was published in 2017. Thomas Balslev, MHPE, PhD, edited the folder. Thomas Balslev is a
consultant at the dep. of Paediatrics, Viborg, and an associate professor at the Centre for
Educational Health Sciences, CESU, Aarhus University, Denmark http://cesu.au.dk/en/. The
folder is sponsored by the Danish Neuropaediatric Society. An unrestricted online access
policy is applied. http://dnps.dk/uddannelse/neurofolder/

Acknowlegements: Dr Robert Smith, MBBS, DRCOG, FRACP, Child Neurologist, John Hunter
Children’s Hospital, NSW, Australia is thanked for valuable comments.
Figure 3
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